A 65-year-old woman with a history of bilateral silicone breast augmentation in 1987 and hypertension presented to clinic with swelling and discomfort of her inferior left breast (Fig. 1). She stated that the symptoms began after a motor vehicle collision 3 years prior. Since that time, the left breast implant had slowly developed significant swelling inferiorly, along with pain and tenderness of the overlying skin. She had initially presented to an outside institution for management, but, due to insurance reasons, could not obtain definitive management. She then presented to our institution nearly 3 years after the initial traumatic injury, during which time she remained hemodynamically stable and asymptomatic with regard to anemia.
Physical examination of the breasts revealed significant capsular contractures bilaterally along with a large, firm, immobile soft-tissue mass of the inferior left breast with overlying skin hyperemia and hypervascularity. In the right breast, there was extensive soft-tissue fullness along superior pole with extension into the axilla. A fluctuant, nontender, 8 × 4 cm soft-tissue mass was palpated within the right upper arm, overlying the medial aspect of brachialis muscle. No accompanying skin changes were seen over the mass. The patient denied systemic (type B) symptoms, skin breakdown, nipple discharge, or retraction, palliating the initial concern for cancerous neoplasm. Her last mammogram was approximately 3 years before presentation and showed no signs of malignancy. She had no prior history of breast cancer. She denied taking any medication with anticoagulant or antiplatelet activity.
Magnetic resonance imaging of the breasts demonstrated large, heterogeneous, oval-shaped masses within the retropectoral spaces bilaterally, concerning for malignancy (Fig. 2). There was also evidence of a fluid collection within the left breast. T1-weighted magnetic resonance images of the right hemithorax showed areas of abnormal high signal intensity, consistent with extracapsular silicone implant rupture extending into the right axilla and upper extremity (Fig. (Fig.2).2). Due to initial suspicion of malignancy, a core biopsy was performed on the inferior left breast mass, which demonstrated benign pathology consistent with an organized hematoma.
The patient was taken to the operating room for bilateral implant removal and total capsulectomy. Complete rupture of the right implant was found, with extrusion of silicone material through the right axilla and upper extremity. An organized hematoma containing fibrinous material and silicone granulomas was evacuated from the right breast, with a total volume of approximately 200 mL. The extruded silicone was removed through an incision within the right bicipital groove (video below). In the left breast, a ruptured 300 cc silicone implant was found inside a fibrous capsule. A large volume of organized hematoma (~600 cc) was removed piecemeal from the inferior aspect of the left breast, and the hyperemic overlying skin was discarded. Bilateral gross specimens were sent for final pathology, both showing benign hematoma with scattered granulomatous reaction; specific staining for anaplastic large-cell lymphoma was negative. All incisions were closed primarily, with drains placed into each breast pocket.
Postoperatively, the patient received 4 units of packed red blood cells due to significant blood loss during the hematoma removal, but otherwise recovered well with no acute events or evidence of hemodynamic instability. At follow-up 1 month later, the patient was doing well, with no further complaints or complications (Fig. 4).
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